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Surg Endosc. 2019 Feb;33(2):592-606. doi: 10.1007/s00464-018-6379-6. Epub 2018 Aug 20.

A task and performance analysis of endoscopic submucosal dissection (ESD) surgery.

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Department of Computer Science, University of Arkansas at Little Rock, Little Rock, AR, United States.
Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
Rensselaer Polytechnic Institute, Troy, NY, United States.
Department of Computer Science, University of Central Arkansas, 201 Donaghey Ave, Conway, AR, 72035, USA.
Department of Computer Science & Information Systems, Youngstown State University, Youngstown, OH, USA.
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
NYU Winthrop Hospital, New York, NY, USA.



ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries.


We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons.


The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores.


We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.


Colorectal cancer; ESD; Endoscopic submucosal dissection; Endoscopic training

[Available on 2020-02-01]

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